(  http://www.insideindonesia.org/weekly-articles/dying-for-nothing )

Comment by Dr. Remco van de Pas - Public health advisor Medecins du Monde


Bobby Anderson's article `dying for ...nothing` provides relevant insights into the health status of indigenous people in the highlands of Papua, as well as the current functioning of
the health care system. Indeed, the already existing fragile health care provision in the highlands has deteriorated despite, or even due to, special autonomy funding, and the creation of new districts (Pemekaran). This deficiency is even more so visible due to a generalized, growing, HIV epidemic, a high incidence of Sexual Transmittable Infections and Tuberculosis infection rates. There is large demand and need for care (as can be seen at the Kalvari Clinic in Wamena), without any proper detection of diseases or follow-up for treatment and care at the village level. In a visit that I made in March 2014 to the highlands, the gravity of the situation struck me. There are many young , unemployed, Papuan boys hanging around drunk at the markets in Wamema.

I have been involved with health care in the highlands (Mulia en Sinak, Puncak Jaya and Puncak district respectively). In these remote districts, the health facilities are worse then they were a decade ago. The relative new and staffed government hospital in Mulia, receives patients, but local people have limited trust in the migrant staff. A decade ago, the churches, in agreement with the government still ran a fragile network of health posts staffed by `Mantri`(missionary trained nurses, often men). Nowadays it is not functioning anymore. The Mantri have either retired or the younger ones have been employed by the government. Replacement with younger nurses and midwifes (both men and women, Papuans and migrants) in government service has taken place. It proves difficult to have these younger staff actually present at their post in the villages, as their education, family, housing etc. is mainly located in the cities.

However, the failing governance of the health care system is only one of the factors why the health of highland Papuans is lagging behind that of other Indonesian citizens. In a recent article in the online journal Inside Indonesia , Jenny Munro highlights some of the more structural determinants why education in Papua is failing. To a considerable extend, these factors are similar for the failing of the health system. The socio-economic marginalisation of the Papuan highland population; a large influx of migrants being the main beneficiaries of the economic growth in the highland districts; the cultural, psychological and physical violence by the state government and its armed forces all have big impact on the health of the indigenous population. The data cannot be retrieved from national statistics, but I would argue that the life expectancy of highland Papuans is about 10-15 year shorter than the national average. Big health inequalities between Papuans and non-Papuans are a real issue.

Governance of the health system
In contrary to what Anderson writes, a `Papuanisation` of the government health workforce is not taking place. Especially the specialized (doctors) and senior management functions (e.g. in the hospital or health authorities) are occupied by non -(highland) Papuans. The salaries in these remote districts are good, and oversight, accountability and adequate enforcement by local bureaucrats, Bupati´s and the legislative bodies poor. This laissez-faire attitude and even corruption, also tolerated by the national government, makes that managers and health workers don´t feel pressured to be at their position. Please note that there are some good individual exceptions to this rule, both Papuan and non-Papuan health workers.

Health workers salaries might arrive too late anyway, and there have been cases of clinic directors or administrators running away with the staff salaries. The often young, migrant, general doctors that work in hospitals or clinics come to Papua to earn a good income during one or two years, upon which many of them return home to start a family and further specialisation.

I have noted that a lack of trust is a reason why health services fail. There is a lack of trust from the highland Papuans in essential medication, often tablets, send by the central government and that should be without costs available via the special autonomy funding. Many Papuans still prefer the injections, often antibiotics, that were given in the past by the missionaries. The tablets are considered as `poison` and with a substandard quality deliberately provided to Papuans. On the other hand, migrant staff refuses sometimes to deal with (or pay a home visit to) difficult disease cases or child birth, as one is afraid that if the person passes away, the Papuan community will blame them for his or her death. Lastly, in many districts the government budget for health expenditures is low, with only 3-4 % spend on health. The district legislative bodies rather budget infrastructure and other economic interesting projects.

Determinants of health
Many of the determinants of people to be able to live in good health, lie outside the formal health care system. The World Health Organisation mentions that 30% of a population`s good health status is related to decent health care, while the other 70% is related to the daily living, working, socio-political, cultural and environmental conditions people are living in. The historical imbalances and pressure created by external influences from outside the highlands, whether formerly the Dutch and now the Indonesian government and its armed forces , as well as the different missionary groups and the modern market economy, have led to great differences in health outcomes between Papuans and Non-Papuans. For instance, Papuans have less access to their traditional lands, or the younger generation doesn´t want to work in a garden anymore. This is one of the reasons that malnutrition rate (stunting) in Papuan children under five years is about 40%. Hence, in later life, these children have more difficulties to learn, their immune system remains weak so it is easier to fall ill from an infection like TB or malaria and malnourished mothers have more chance to die during childbirth. This is just one, of many examples, why non -overt violence lead to poor health and early deaths.

Highland Papuans have to struggle with the historical oppression by the state and armed forces. They are however not only victims, but also actors regarding the daily choices they make in life. Although a small group seeks power, individual wealth, and nepotism, many highland families try to make the best of their lives, providing food and shelter for their children, pursuing education, and health care when one is ill. There are numerous examples of highlanders studying in Indonesia and abroad having pursued higher education, including medical degrees. I have met remarkable indigenous nurses and midwifes that with limited means, and often difficult lives, creatively continue their daily work. They know how to let a retained placenta be born via a manual technique, without modern medication. They are the ones that know which nutritious sweet potato variety children should eat when they are undernourished. Although relevant to analyze the failures, and possible solutions of the Papuan health care system, in daily practice all our support should go to those healthworkers, mothers and health volunteers that make the best out of it in a hard and unfair society. We can actually learn with them.